NURSING PROCESS OUTLINE

INTRODUCTION – PROBLEM-SOLVING PROCESS

The nursing process is a method for organizing and delivering nursing care.
It focuses on identification and treatment of unique responses of individuals or
groups to actual or potential alterations in health. It’s a framework that allows
nurses in all settings to identify and meet changing client needs. The process is
sequential and interrelated, each step depending on the previous one. To carry out
the nursing process, it takes the joint efforts of the nurse and client.
What are two critical functions that nurses must master for the nursing
process to be successful with clients? The process is what you go through in order
to write your nursing care plan. In other words, the nursing care plan (NCP) is the
written version of the nursing process. It is the basis for nursing implementation.

FIVE COMPONENTS OF NURSING PROCESS

A. ASSESSMENT - Collecting and organizing information about the
client’s health status.

1. Purpose - Establish a data base. Data collection is the process of

gathering information about a client’s health status.
2. Method - Collecting nursing health history

3. Types of Data Collection

b. Subjective data

c. Objective data

1. Performing physical examination

2. Collecting laboratory data

3. Sources of Data

a. Primary or direct

b. Secondary or indirect
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B. NURSING DIAGNOSIS - A statement describing the client’s response

to a situation/condition resulting in an actual or high risk health
problem/need that the nurse is licensed to identify and competent to
treat.

1. The diagnostic Process - consists of the decision-making steps that

one uses to develop a diagnostic statement

a. Analyze collected data from assessment - cluster data

b. Validate findings with diagnostic categories

c. Choose a diagnostic category that best fits the data you have

2. Two types of nursing diagnoses

a. Actual

A (3) part statement; Problem (Diagnostic Category) as stated by

NANDA R/T Etiology/Cause (Contributing or Risk Factors)
AMB Signs/Symptoms (Defining Characteristics): expressions,
observations, and behaviors of your client

b. High risk

A (2) part statement; Problem (Diagnostic Category) R/T Etiology/

Cause (Contributing or Risk Factors) the validation for this
nursing diagnosis is the presence of risk factors; there are no signs
or symptoms

c. Remember that the client’s response to his illness, condition,

situation, etc. should constitute a problem treatable with nursing
care. When you get ready to do your 1st NCP, review “Avoiding
and Correcting Errors” on pages 257-258 to help you with stating
nursing diagnoses correctly.

3. Differs from a medical diagnosis

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C. PLANNING - During this step, priorities are set, client centered goals
are determined, expected outcomes are developed , and a NCP is
formulated.

1. Prioritize nursing diagnoses (List in descending order of priority)

a. High priority - urgent and immediate

b. Intermediate priority - not life threatening

c. Low priority - not directly related to specific illness or prognosis

2. Set goals with outcome criteria

a. Purpose (two-fold) - Provide direction for 1) planning nursing

actions to eliminate/relieve problem or to correct the etiology of
the problem 2) evaluating the effectiveness of nursing actions

b. Client centered

c. A goal or expected outcome is a statement about the expected or

desired changes in the client’s status as a result of nursing care. A
goal must be determined for every nsg dx

d. Goal statements - derived directly from nsg dx; the goal is broad
followed by a more specific outcome criteria. Outcome criteria
seek to eliminate vagueness by being very descriptive; For a
complete goal statement, you need :

1. Subject - client
2. Verb - Action
3. Condition - Under what circumstances
4. Criteria - How well
5. Specific time - target date
Goals need to be realistic, mutually agreed upon by the nurse and
client, client centered, measurable, specific, and timed

e. Types of goals - Specific time frame; connected with expected

outcomes with the phrase “as manifested by” or “AMB”
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1. Short term - goals that can be achieved in a short period of

time

2. Long term - goals achieved over a longer period of time

3. Design nursing interventions (nursing actions)

a. Types of nursing interventions

1. Nurse-initiated ( Independent)

2. Physician-initiated (Dependent)

3. Collaborative (Interdependent)

b. Components of an intervention

1. Action verb - Assess, instruct, teach, ambulate etc.

2. Content - Who, where, and what
3. Time element - When, how often, and for how long
4. Scientific rationale - Supports reason an action is selected
or prescribed. Document the source and page #
(theoretical validation for intervention)

4. Types of Care Plans

a. Kardex NCPs
-Trade name for a card-filing system that allows quick
reference to the particular needs of the client for certain aspects
of nursing care
b. Standardized/Computerized NCPs
-Preprinted
-Gives basic standards of care for a specific condition
-Saves the nurse time
-May fulfill the agency’s requirements of a NCP on every client
c. Individualized NCPs (Student Care Plans)
-Prepared specifically to the needs of a client
-May add to or delete from a standardized care plan information
to individualize for a client’s needs

D. IMPLEMENTATION - Involves the actual carrying out of the plan of

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care. Adequate and thorough preparation before implementing the NCP

ensures efficient and effective nursing care.

E. EVALUATION - This component primarily determines to what extent

goals have been met and how effective interventions were. Each goal
and intervention should be evaluated specifically

1. Components of evaluation

a. Review the outcome criteria (OC)

b. Collect subj and obj data R/T OC
c. Evaluate if goal is met, unmet or partially met by comparing the
OC with new data collected about the client. Were goals realistic?
Were actions effective?

2. If client’s status has changed, may need to identify new nsg dxes

3. Based on the evaluation, revisions or modifications may need to be

made to reflect the current status of the client. This serves to
enhance continuity of care.